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Nutrition in AKI. Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University. Nutrition In AKI. Objectives: Overview Nutritional Needs in Children with AKI

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Nutrition in aki

Nutrition in AKI

Norma J Maxvold MD

Associate Professor of Pediatrics

Pediatric Critical Care Medicine

Children’s Hospital of Richmond

Virginia Commonwealth University

Nutrition in aki1

Nutrition In AKI


  • Overview Nutritional Needs in Children with AKI

  • Effect of renal support on Nutrition

  • Diagram of Nutrition Prescription during AKI

Nutrition in aki2

Nutrition in AKI






Impaired AA Conversion, iLipid Oxidation

Acute Illness: Stress Response

hCytokines, Hormonal changes,

Altered Substrate Utilization


Energy expenditure

Energy Expenditure

  • Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure

  • Pediatric patients may not exhibit significant hypermetabolism post-injury?

Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus and Jaksic (2002)

Nutrition in aki

  • Substrate Utilization/Nutrient Composition

    75%CHO:15% AA: 10% Lipid

    15%CHO: 15%AA: 70% Lipid

    C13 Glucose, C13 Acetate

    Maximum Glu Oxidation 4mg/kg/min

    Lipogenesis from Excess Glucose Metabolism

    Gluconeogenesis and Protein Catabolism was not effected

    [Tappy et al. Crit Care Med 1998;26:860-867]

Hypermetabolism in children with critical illness

Hypermetabolism in Children with Critical Illness

AveEnergy Intake REE

Coss-Bu( Am J Clin Nutr 2001)0.23 MJ/kg/d>25%

Verhoeven(Int Care Med 1998) 0.24 MJ/kg/d >14%

Joosten (Nutrition 1999) 0.26 MJ/kg/d >20%

Comparison of mee vs cree

Comparison of MEE vs. cREE

Briassoulis et al. (2000)

Indirect calorimetry and crrt

Indirect calorimetry AND CRRT

  • IC: measure resting energy expenditure.

  • Based on: Expired CO2 and O2 (O2 consumption + CO2 production).

    Potential problem with CRRT

May affect IC


IC may not be


HCO3/CO2 fluxes



Dialysis fluid

Nutrition in aki3

Nutrition in AKI

Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J ClinNutr2001;74:664

Normal Metabolic : Hypermetabolic

mREE 0.16 mREE 0.28

Fat Oxidation -22mg/min Fat Oxidation 27mg/min

np RQ 1.21 npRQ 0.86

Energy Intake: 0.25MJ/kg/d [55kcal/kg/d]

CHO: 10 g/kg/d ; Fat: 1.4g/kg/d;


Nutrition in aki4

Nutrition in AKI

No Growth occurs during Acute Illness

Focus : Prevent Malnutrition

Children at Risk:

High basal rate of metabolism

Limited reserves

Baseline poor nutrition


Uremia and acidosis

Altered renal Amino Acid metabolism, lipid metabolism,

Fluid and Solute Clearance,


hLosses for Renal Replacement Therapy

Protein turnover in renal disease

Protein Turnover in Renal Disease

UNA/ PCR in Acute Kidney Injury

  • Adult Studies:

  • Protein Catabolic Rate ~ 1.4 - 1.7 g/kg/d

    [Macias WL, et al. JPEN 1996;20:56-62]

    [Chima CS, et al. JASN 1993; 3:1516-1521]

    Pediatric Studies: Urea Nitrogen Appearance

    UNA ~ 185- 290mg/kg/d (PCR 1.1- 1.8 g/kg/d)

    [ Kuttnig M, et al. Child NephrolUrol 1991;11:74-78]

    [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]

Nutrition in aki5

Nutrition in AKI

Caloric Support:

Protein Support:


npkcal 25kcal/kg/d

CHO 5 g/kg/d

Fat 0.8-1.2g/kg/d


Npkcal 40-65kcal/kg/d


Protein 1.5-2.0 g/kg/d


Protein 2.0-3.0 g/kg/d

( Cano N et al ClinNutr 2006 and 2008)

Nutrition and pcrrt

Nutrition and PCRRT

Can Nitrogen Balance be Achieved

in AKI patients on CRRT?

Conflicting Studies

Bellomo et al Ren Fail 1997

Protein Intake : Nitrogen Balance

1.2 g/kg/d AA -5.5 g N /d

2.5 g/kg/d AA -1.9 g N /d

Does increasing protein intake help

Does increasing protein intake help?

  • Scheinkestel et al.

    1. Nutrition, 2003

    In 11 critically ill adults on CRRT, protein intake 2.5 g/kg/day led to a) normal amino acid levels and b) positive nitrogen balance.

    2. Nutrition, 2003

    50 critically ill adults on CRRT: 1.5 vs 2.0 vs 2.5 g/kg/day.

    NB related to protein intake.

    NB related to hospital stay

    Protein intake 2.5 g/kg/d: improved survival!

Potential for losses during CRRT

Glutamine supplementation

Glutamine Supplementation

[Ziegler et al, Ann Intern Med 1992;116:821]

45 BMT patients with Parenteral Glutamine (L-Gln) Supplemention : 0.57g/kg/d Gln &2.07g/kg/d AA Intake

Improved Nitrogen Balance: -1.4g/d vs -4.2g/d

i Clinical infections: 3/24 vs 9/21

  • Hospital stay: 29 days vs 36 days

    [ Schloerb et al; JPEN 1993; 17:407-413]

  • Hospital stay: 26 days vs 32 days

  • Total Body Water: -1.2 L vs 2.2 L (Bioimpedance)

Nutrition and pcrrt1

Nutrition and PCRRT

Lipid Metabolism

 Fatty Acid Utilization during acute illness

Mitochondrial adaptation to acute stress

(Carnitine dependent enzymes)

Calvani et al Basic Res Cardiol 2000

Mitochondrial control of FFA oxidation and CHO oxidation

AcetylCoA/ CoA ratio on PDH Complex

Smoflipid iv emulsion

SMOFlipid IV Emulsion


  • Lower Linoleic concentration

  • MCT rapidly cleared from plasma

  • Olive oil less prone to peroxidation

  • Fish oil beneficial anti-inflammatory

    Early Studies : Good Safety profile

    ClinNutr 2013;32:224

    JPEN 2012; 36:81S

Potential for losses during crrt

Potential for losses during CRRT

Water Soluble Vitamins

  • Vit B1 Def Altered Energy Metabolism,

    h Lactic Acid, Tubular damage

  • Vit B6Def Altered Amino acid and lipid


  • FolateDef Anemia

  • Vit C Def Limit 200 mg/d as precursor to

    Oxalic acid

Nutrition in children with aki

Nutrition in Children with AKI

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